Guidelines on urolithiasis

(Update March 2011)

C. Türk (chairman), T. Knoll (vice-chairman), A. Petrik, K. Sarica, C. Seitz, M. Straub

epidemiology
Between 120 and 140 per 1000,000 will develop urinary stones each year with a male/female ratio of 3:1. A number of known factors of influence to the development of stones are discussed in more detail in the extended version of the Urolithiasis guidelines.

Classification of stones
Correct classification of stones is important since it will impact treatment decisions and outcome. Urinary stones can be classified according to the following aspects: stone size, stone location, X-ray characteristics of stone, aetiology of stone formation, stone composition (mineralogy), and risk group for recurrent stone formation (Tables 1-3).

Urolithiasis 289

table 1: X-ray characteristics
Radiopaque Calcium oxalate dihydrate Calcium oxalate monohydrate Calcium phosphates Poor radiopaque Radiolucent Magnesium ammonium phosphate Apatite Cystine Uric acid

Ammonium urate Xanthine 2,8-dihydroxyadenine ‘Drug-stones’

table 2: stones classified according to their aetiology
Noninfection stones Calcium oxalates Calcium phosphates Uric acid Infection stones Magnesiumammoniumphosphate Apatite Ammonium urate Genetic stones Cystine Drug stones

Indinavir
(see extended document)

Xanthine 2,8-dihydroxyadenine

290 Urolithiasis

table 3: stones classified by their composition
Chemical composition Calcium oxalate monohydrate Calcium-oxalate-dihydrate Uric acid dihydrate Ammonium urate Magnesium ammonium phosphate Carbonate apatite (phosphate) Calcium hydrogenphosphate Cystine Xanthine 2,8-dihydroxyadenine ‘Drug stones’ unknown composition. struvite dahllite brushite Mineral whewellite wheddelite uricite

risk groups for stone formation
The risk status of a stone former is of particular interest as it defines both probability of recurrence or (re)growth of stones and is imperative for pharmacological treatment (Table 4, Figure 1).

table 4: high risk stone formers
General factors Early onset of urolithiasis in life (especially children and teenagers) Urolithiasis 291

B. AB) Primary hyperoxaluria (PH) Renal tubular acidosis (RTA) type I 2. CaHPO4. but the prevention of a potential stone recurrence is of more importance) Diseases associated with stone formation Hyperparathyroidism Nephrocalcinosis Gastrointestinal diseases or disorders (i.2H2O) Uric acid and urate containing stones Infection stones Solitary kidney (The solitary kidney itself does not have a particular increased risk of stone formation.e. malabsorptive conditions) Sarcoidosis Genetically determined stone formation Cystinuria (type A. intestinal resection.8-dihydroxyadenine Xanthinuria Lesh-Nyhan-Syndrome Cystic fibrosis Drugs associated with stone formation (see Chapter 11 extended text) 292 Urolithiasis . jejuno-ileal bypass.Familial stone formation Brushite containing stones (calcium hydrogen phosphate. Crohn’s disease.

Urolithiasis 293 LE 4 GR A* . Ultrasonography should be used as the primary procedure. *Upgraded following panel consensus. immediate imaging is indicated. Recommendation In patients with fever or a solitary kidney. calyceal cyst Ureteral stricture Vesico-uretero-renal reflux Horseshoe kidney Ureterocele Urinary diversion (via enteric hyperoxaluria) Neurogenic bladder dysfunction diaGnosis diagnostic imaging Standard evaluation of a patient includes taking a detailed medical history and physical examination. The clinical diagnosis should be supported by an appropriate imaging procedure. and when the diagnosis of stone is in doubt.Anatomical abnormalities associated with stone formation Medullary sponge kidney (tubular ectasia) UPJ obstruction Calyceal diverticulum. KUB should not be performed in case an NCCT is considered.

294 Urolithiasis . Recommendation Use NCCT in confirming a stone diagnosis in pts presenting with acute flank pain because it is superior to IVU.Figure 1: Assessement of patients to low-risk or high-risk STONE Stone analysis + Basic evaluation Risk factors present? no yes Low recurrence risk High recurrence risk Specific metabolic evaluation General preventive measures Stone specific recurrence prevention evaluation of patients with acute flank pain Non-contrast enhanced computed tomography (NCCT) has become the standard for diagnosis of acute flank pain and has higher sensitivity and specificity than IVU. LE 1a GR A Indinavir stones are the only stones not detectable on NCCT.

LE 3 GR A* Biochemical work-up Each emergency patient with urolithiasis needs a succinct biochemical work-up of urine and blood besides the imaging studies. *Upgraded following panel consensus.Recommendation When planning treatment of a renal stone a renal contrast study (preferable enhanced CT or IVU) is indicated. At that point no difference is made between high and low risk patients. Recommendation: Basic analysis Emergency stone patient Urine Urinary sediment/dipstick test out of spot urine sample for: red cells / white cells / nitrite / urine pH level by approximation Urine culture or microscopy Blood Serum blood sample creatinine / uric acid / ionized calcium / sodium / potassium Blood cell count CRP If intervention is likely or planned: Coagulation test (PTT and INR) *Upgraded following panel consensus Urolithiasis 295 A* GR A* A A* A* .

and repeated in case A of: • ecurrence under pharmacological prevention R • arly recurrence after interventional therapy with comE plete stone clearance • ate recurrence after a prolonged stone-free period L (GR: B) The preferred analytical procedures are: • -ray diffraction X • nfrared spectroscopy I Wet chemistry generally deems as obsolete. Analysis of stone composition should be performed in: • ll first-time stone formers (GR: A) .Examination of sodium. acute treatment of a patient with renal colic Pain relief is the first therapeutic step in patients with an acute stone episode. 296 Urolithiasis LE 1b GR A . Recommendations for pain relief during and prevention of recurrent renal colic First-line treatment: treatment should be started with an NSAID Diclophenac sodium*. Indomethacin. Only patients at high risk for stone recurrences should undergo a more specific analytical programme (see section MET below). CRP. and blood coagulation time can be omitted in the non-emergency stone patient. potassium. Ibuprofen.

) are alternatives which may be given in circumstances in which parenteral administration of a non-narcotic agent is mandatory. but not in patients with normal renal function (LE: 2a). infected kidney is a urological emergency. should be carried out. Management of sepsis in the obstructed kidney The obstructed. Urolithiasis 297 . using stenting or percutaneous nephrostomy. or stone removal. given on a daily basis. If pain relief cannot be achieved by medical means. Third-line treatment: Spasmolytics (metamizole sodium etc. Alpha-blocking agents. NSAID = non-steroidal antiinflammatory drug.Second-line treatment: Hydromorphine Pentazocine Tramadol Diclofenac sodium* is recommended to counteract recurrent pain after an episode of ureteral colic. *Caution: Diclofenac sodium affects GFR in patients with reduced renal function. drainage. 4 C 1b A GFR = glomerular filtration rate. also reduce the number of recurrent colics.

the 1b collecting system should be urgently decompressed. 298 Urolithiasis . Definitive treatment of the stone should be delayed until sepsis is resolved. Revisit antibiotic treatment regimen following antibiogram findings. Further Measures . GR A* stone relief When deciding between active stone removal and conservative treatment using MET. an emergency nephrectomy may become necessary. * Upgraded based on panel consensus. using either percutaneous drainage or ureteral stenting.Recommendations Collect urine following decompression for antibiogram.Recommendation LE GR A* For septic patients with obstructing stones. * Upgraded following panel consensus. Start antibiotic treatment immediatedly thereafter (+ intensive care if necessary). In exceptional cases. with severe sepsis and/or the formation of abscesses. it is important to carefully consider all the individual circumstances of a patient that may affect treatment decisions.

Such patients may be offered appropriate medical therapy to facilitate stone passage during the observation period*. periodic evaluation is needed. or whether annual follow-up is sufficient in an asymptomatic caliceal stone which has remained stable for 6 months. observation of kidney stones It is still debatable whether kidney stones should be treated.1a al stone < 10 mm and if active stone removal is not indicated. * Upgraded following panel consensus. Recommendations Kidney stones should be treated in case of stone growth. GR* A C A Urolithiasis 299 . Patient’s comorbidities and preferences (social situation) need to be taken into consideration when making a treatment decision. *see also Section MET. and acute and/or chronic pain. observation with periodic evaluation is an option as initial treatment. formation of de novo obstruction. If kidney stones are not treated. associated infection.observation of ureteral stones Recommendations LE GR A In a patient who has a newly diagnosed ureter.

100-150 mg/day. Recommendations for MET For MET. should have wellcontrolled pain. MET in children cannot be recommended due to the limited data in this specific population. diclofenac sodium. 4 4 LE GR A A* A A* C 300 Urolithiasis . Patients. also reduce the number of recurrent colic (LE: 1a).Medical expulsive therapy (Met) For patients with ureteral stones that are expected to pass spontaneously. and should be informed that it is administered as ‘off-label’ use. and adequate renal functional reserve. has been the most commonly used alpha blocker in studies.e. NSAID tablets or suppositories (i. who elect for an attempt at spontaneous passage or MET. given on a daily basis. over 3-10 days) may help to reduce inflammation and the risk of recurrent pain. Patients should be counselled about the attendant risks of MET. Tamsulosin. Patients should be followed to monitor stone position and to assess for hydronephrosis. Alpha-blocking agents. no clinical evidence of sepsis. *Upgraded following panel consensus. alpha-blockers or nifedipine are recommended. including associated drug side effects.

PNL. reducing additional analgesic requirements. Percutaneous irrigation chemolysis Recommendations In percutaneous chemolysis.and flow-controlled systems should be used if available. at least two nephrostomy catheters should be used to allow irrigation of the renal collecting system. After ESWL for ureteral or renal stones.Corticosteroids in combination with alpha-blockers may expedite stone expulsion compared to alpha-blockers alone (LE: 1b). However. MET seems to expedite and increase stone-free rates. GR A Urolithiasis 301 . its use as first-line therapy may take weeks to be effective. Pressure. Statements MET has an expulsive effect also on proximal ureteral stones. while preventing chemolytic fluid draining into the bladder and reducing the risk of increased intrarenal pressure. Chemolytic dissolution of stones Oral or percutaneous irrigation chemolysis of stones can be a useful first-line therapy or an adjunct to ESWL. or open surgery to support elimination of residual fragments. URS.

The urine pH should be adjusted to between 7.0 N-acetylcysteine (200 mg/L) Trihydroxymethylaminomethan (THAM.0 Cystine Uric acid oral Chemolysis Oral chemolitholysis is efficient for uric acid calculi only.6 mol/L) with pH range 8.2. 302 Urolithiasis .0 and 7.5-4 Suby’s G Comments Combination with ESWL for staghorn stones Risk of cardiac arrest due to hypermagnesaemia Can be considered for residual fragments Takes significantly longer time than for uric acid stones Used for elimination of residual fragments Oral chemolysis is the preferred option Brushite Hemiacidrin Suby’s G Trihydroxymethylaminomethan (THAM.3 or 0.Methods of percutaneous irrigation chemolysis Stone composition Struvite Carbon apatite Irrigation solution 10% Hemiacidrin with pH 3.3 or 0.5-9.5-9. 0.6 mol/L) with pH range 8. 0.

GR A A A esWl The success rate for ESWL will depend on the efficacy of the lithotripter and on: • ize. location of stone mass (ureteral. The physician should clearly inform the patient of the significance of compliance. Dipstick monitoring of urine pH by the patient is required at regular intervals during the day. S and composition (hardness) of the stones • atient’s habitus P • erformance of ESWL P Contraindications of esWl Contraindications to the use of ESWL are few. pelvic or caliceal). which S will not allow targeting of the stone • rterial aneurism in the vicinity of the stone treated A • natomical obstruction distal of the stone A Urolithiasis 303 . which is a direct consequence of the alkalising medication.Recommendations The dosage of alkalising medication must be modified by the patient according to the urine pH. but include: • regnancy P • leeding diatheses B • ncontrolled urinary tract infections U • evere skeletal malformations and severe obesity. Morning urine must be included.

304 Urolithiasis . • linical reality is that repeat sessions are feasible (within C 1 day in case of ureteral stones). Recommendation .0 (to 1.recommendation Routine stenting is not recommended as part of ESWL treatment of ureteric stones.5) Hz. as some devices need to be de-activated during ESWL. • tarting ESWL using a lower energy setting with step-wise S power ramping prevents renal injury.stenting prior to esWl Kidney stones A double-J stent reduces the complications (evidence of renal colic) but does not reduce formation of steinstrasse or infective complications.Shock wave rate The optimal shock wave frequency is 1. Ureteric stones . LE 1b GR A Best clinical practice (best performance) Pacemaker Patients with a pacemaker can be treated with ESWL provided the patient’s cardiologist is consulted before ESWL is undertaken. LE 1a GR A number of shock waves. energy setting and repeat treatment sessions • he number of shock waves that can be delivered at each T session depends on the type of lithotripter and shockwave power. Patients with implanted cardioverter defibrillators must be managed with special care.

along with a reduction in additional analgesic requirements. Recommendation LE GR C 4 Antibiotics should be given before ESWL and continued for at least 4 days after treatment.Procedure control The results of treatment are operator dependent. Careful imaging control of localisation will contribute to the quality of outcome. Medical expulsive therapy (Met) after esWl MET after ESWL for ureteral or renal stones can expedite expulsion and increase stone free rates. antibiotic prophylaxis No standard prophylaxis prior to ESWL is recommended. Pain control Careful control of pain during treatment is necessary to limit pain induced movements and excessive respiratory excursions. Urolithiasis 305 . in the case of infected stones or bacteriuria.

T • otential malignant tumour of the kidney. * Upgraded based on panel consensus. and ensure safe access to the kidney stone.Recommendation Pre-procedural imaging. the patient is positioned prone for PNL. which includes a contrast media study. P • regnancy (conservative stone treatment should be conP sidered first. ballistic and Ho:YAG devices are recommended for intracorporeal lithotripsy using rigid nephroscopes. U • typical bowel interposition. GR A* Best clinical practice (best performance) Contraindications: • ll contraindications for general anaesthesia apply. GR A* Positioning of the patient: prone or supine? Traditionally. A • umour in the presumptive access tract area. * Upgraded following panel consensus. the Ho:YAG laser is currently the most effective device available. where possible (GR: A). When using flexible instruments. Pre-operative imaging . the anatomy of the collecting system.Percutaneous nephrolitholapaxy (Pnl) Recommendation Ultrasonic. how306 Urolithiasis . is mandatory to assess stone size. A • ntreated urinary infection.

the possibility of simultaneous retrograde transurethral manipulation. ureterorenoscopy (urs) (including retrograde access to renal collecting system) Best clinical practice in urs Before the procedure. nephrostomy and stents after Pnl Recommendation LE GR A 1b In uncomplicated cases. However. the following information should be available (LE: 4): • atient’s history P • hysical examination (i. showing advantages in shorter operating time.e. an easier anaesthesia and disadvantages like limitations in the maneuvrability of instruments and the need of appropriate equipment.ever supine position has been described. URS can be performed in patients with bleeding disorders. tubeless (without nephrostomy tube) or totally tubeless (without nephrostomy tube and without ureteral stent) PNL procedures provide a safe alternative. with only a moderate increase in complications • maging I Urolithiasis 307 . to detect anatomical and conP genital abnormalities) • hrombocyte aggregation inhibitors/anticoagulation T treatment should be discontinued.

impacted proximal ureteral calculi.Recommendation Short-term antibiotic prophylaxis (< 24 hours) should be administered. especially in women. GR A* ureteral access sheaths Hydrophilic-coated ureteral access sheaths (UAS). Intravenous sedation is possible for distal stones. Antegrade URS is an option for large. If ureteral access is not possible. access to the upper urinary tract Most interventions are performed under general anaesthesia. with the tip placed in the proxi308 Urolithiasis . the insertion of a double-J stent followed by URS after a delay of 7-14 days offers an appropriate alternative to dilatation. although it is possible to use spinal anaesthesia. Recommendation Placement of a safety wire is recommended. safety aspects Fluoroscopic equipment must be available in the operating room. GR A Contraindications Apart from a general considerations related to general anaesthesia. can be inserted via a guide wire. *Upgraded following panel consensus. URS can be performed in all patients without any specific contraindications.

GR B LE 4 GR A* 3 B stenting prior to and after urs Pre-stenting facilitates the ureteroscopic management of stones. Recommendations Stone extraction using a basket without endoscopic visualisation of the stone (blind basketing) should not be performed. Stents should be inserted in patients who are at increased risk of complications. Nitinol baskets are most suitable for use in flexible URS. as ‘smash and go’ strategies leave patients with a higher risk of stone regrowth and post-operative complications. In patients with large stone mass UAS promotes improved stone-free rates and reduced OR-time. Nitinol baskets preserve the tip deflection of flexible ureterorenoscopes. Urolithiasis 309 . *Upgraded following panel consensus. and the tipless design reduces the risk of mucosa injury. and reduces the complication rate.mal ureter. stone extraction The aim of endourological intervention is to achieve complete stone removal. Recommendation Ho:YAG laser lithotripsy is the preferred method when carrying out (flexible) URS. improves the stone-free rate.

nonN functioning kidney (nephrectomy) • atient choice following failed minimally invasive proceP dures. LE 1a GR A open surgery Most complex (staghorn) stones. contractures and fixed deformities of S hips and legs • o-morbid medical disease C • oncomitant open surgery C • on-functioning lower pole (partial nephrectomy). stone in the calyceal diverticulum (particularly in an anterior calyx).Recommendation Stenting is optional before and after uncomplicated URS. obstruction of the ureteropelvic junction. the patient may prefer a single procedure and avoid the risk of needing more than one PNL procedure • tone in an ectopic kidney where percutaneous access and S ESWL may be difficult or impossible 310 Urolithiasis . or failed ureteroT scopic procedure • ntrarenal anatomical abnormalities: infundibular stenoI sis. should be approached primarily with PNL or a combination of PNL and ESWL. stricture • orbid obesity M • keletal deformity. Open surgery may be a valid primary treatment option in selected cases. indications for open surgery: • omplex stone burden C • reatment failure of ESWL and/or PNL.

laparoscopic surgery Laparoscopic urological surgery has increasingly replaced open surgery. URS. LE 4 GR C Urolithiasis 311 . and percutaneous URS fail or are unlikely to be successful.• or the paediatric population. impacted stones L • ultiple ureteral stones M • n cases of concurrent conditions requiring surgery I • hen other non-invasive or low-invasive procedures have W failed Laparoscopic ureterolithotomy should be considered when other non-invasive or low-invasive procedures have failed. Indications for laparoscopic kidney-stone surgery include: • omplex stone burden C • ailed previous ESWL and/or endourological procedures F • natomical abnormalities A • orbid obesity M • ephrectomy in case of non-functioning kidney N Indications for laparoscopic ureteral stone surgery include: • arge. Recommendations Laparoscopic or open surgical stone removal may be considered in rare cases where ESWL. the same considerations F apply as for adults.

single kidney) Kidney: • Stone growth • Stones in high-risk patients for stone formation • Obstruction caused by stones • Infection • Symptomatic stones (e. bilateral obstruction. laparoscopic surgery should be the preferred option before proceeding to open surgery. haematuria) • Stones > 15 mm • Stones < 15 mm if observation is not the option of choice • Patient preference (medical and social situation) • > 2-3 years persistent stones The suspected stone composition might influence the choice of treatment modality. 4 C indication for active stone removal and selection of procedure Ureter: • Stones with a low likelihood of spontaneous passage • Persistent pain in spite of adequate pain medication • Persistent obstruction • Renal insufficiency (renal failure. 312 Urolithiasis .When expertise is available.g. pain. An exception will be complex renal stone burden and/or stone location.

Statements For asymptomatic caliceal stones in general. Radiolucent uric acid stones. LE 4 stone reMoVal Recommendations Urine culture is mandatory before any treatment is planned. can be dissolved by oral chemolysis. active surveillance with an annual follow-up evaluation of symptoms and the status of the stone by appropriate means (KUB. Urinary infection should be treated when stone removal is planned. but not sodium urate or ammonium urate stones. Salicylates should be stopped before planned stone removal. whereas intervention should be considered after this period provided patients are adequately informed. Observation might be associated with a greater risk of necessitating more invasive procedures. If intervention for stone removal is essential and salicylate therapy should not be interrupted. ultrasonography [US]. Determination is done by urinary pH. NCCT) is an option for a reasonable period (the first 2–3 years). retrograde URS is the preferred treatment of choice. B GR A Urolithiasis 313 .

PNL 314 Urolithiasis . Flexible URS 4. ESWL 3. Laparoscopy No 1-2 cm Yes 1. * Upgraded based on panel consensus. ESWL 2. ESWL 2. Flexible URS 3.Recommendation Careful monitoring of radiolucent stones during/after therapy is imperative. PNL 3. Figure 2: Selection of procedure for active removal of kidney stones (Gr: A) Kidney stone in renal pelvis or upper/middle calyx GR* A > 2 cm Yes 1. Flexible URS No < 1 cm Yes 1. PNL 2.

ESWL 2. ESWL No Yes 1-2 cm Yes Favourable factors for ESWL (see table) No PNL No ESWL < 1 cm Yes 1. PNL 2. Patients should be informed that URS is associated with a Urolithiasis 315 .Figure 3: Treatment algorithm for lower pole calculi Lower Pole > 2 cm Yes 1. Flexible URS selection of procedure for active stone removal of ureteral stones (Gr: a*) First choice Proximal ureter < 10 mm ESWL Second choice URS Proximal ureter > 10 mm URS (retrograde or antegrade) or ESWL Distal ureter < 10 mm URS or ESWL ESWL Distal ureter > 10 mm URS *Upgraded following panel consensus.

but has higher complication rates. Performing of percutaneous nephrostomy is indicated in evidence of UTI/ fever associated with steinstrasse. Performing of ureteroscopy is indicated the treatment of symptomatic steinstrasse and in treatment failures. and when the upper urinary tract is not amenable to retrograde URS. GR A Steinstrasse occurs in 4% to 7% cases of ESWL. the major factor of formation of steinstrasse is stone size. Recommendations Medical expulsion therapy increases the stone expulsion rate of steinstrasse. Performing of ESWL is indicated in the treatment of steinstrasse when larger stone fragments are presented. LE 1b 4 GR A C 4 C 4 C 316 Urolithiasis . Recommendation Percutaneous antegrade removal of ureteral stones is an alternative when ESWL is not indicated or has failed.better chance of achieving stone-free status with a single procedure.

inversion therapy during high diuresis and mechanical percussion facilate stone clearance. adjunctive treatment with tamsulosin could improve fragment clearance and reduce the probability of residual stones. Urolithiasis 317 . After ESWL and URS. For well-disintegrated stone material residing in the lower calix.residual stones Recommendations Identification of biochemical risk factors and appropriate stone prevention is particularly indicated in patients with residual fragments or stones. LE 1b GR A 4 C 1a A 1a B The indication for active stone removal and selection of the procedure is based on the same criteria as for primary stone treatment and also includes repeat ESWL. Patients with residual fragments or stones should be followed up regularly to monitor the course of their disease.

Children with renal stones with a diameter up to 20 mm (~300 mm2) are ideal candidates for ESWL. Management of stone problems in children Spontaneous passage of a stone and of fragments after ESWL is more likely to occur in children than in adults (LE: 4). placement of a internal stent. conservative management should be the first-line treatment for all non-complicated cases of urolithiasis in pregnancy. 318 Urolithiasis . or ureteroscopy are treatment options. however they pass fragments more easily. If intervention becomes necessary. A limited IVU. * some upgraded by panel consensus. or isotope renography are a useful diagnostic methods. percutaneous nephrostomy. For paediatric patients. the indications for ESWL and PNL are similar to those in adults. MRU. Regular follow-up until final stone removal is necessary due to higher lithogenic activity during pregnancy.ManaGeMent oF urinarY stones and related ProBleMs durinG PreGnanCY Recommendations (GR: A*) Ultrasonography is the method of choice as primary diagnostic imaging. Following the establishment of the correct diagnosis.

Incision with an Acucise balloon catheter might also be considered. Passage of fragments after ESWL might be poor. PNL (if possible) or RIRS (retrograde intrrenal surgery via flexible ureteroscopy). Can also be removed using video-endoscopic retroperitoneal surgery. Transureteral endopyelotomy with Ho:YAG laser endopyelotomy can also be used to correct this abnormality.Recommendation US evaluation is the first choice for imaging in children and should include the kidney. *Upgraded from B following panel consensus. Horseshoe kidneys Patients with obstruction of the ureteropelvic junction Urolithiasis 319 . If there is only a narrow communication between the diverticulum and the renal collecting system. well-disintegrated stone material will remain in the original position. stones can be removed with either percutaneous endopyelotomy or open reconstructive surgery. GR A* stones in exceptional situations Caliceal diverticulum stones ESWL. provided the stones can be prevented from falling into the pelvo-ureteral incision. the filled bladder and adjoining portions of the ureter. Can be treated in line with the stone treatment options described above. Patients may become asymptomatic due to stone disintegration only. When the outflow abnormality has to be corrected.

neutral pH) • Balanced diet • Lifestyle advice high-risk patients: stone-specific metabolic work-up and pharmacological recurrence prevention Pharmacological stone prevention is based on a reliable stone analysis and the laboratory analysis of blood and urine including two consecutive 24-hours urine samples. Each stone problem must be considered and treated individually.5 – 3L/day. however ESWL or (flexible) ureteroscopy are valuable alternatives. For stone removal all methods apply based on individual situation. For smaller stones ESWL is effective.Stones in transplanted kidneys Stones in patients with urinary diversion Use of PNL is recommended. Present a varied and often difficult problem. Individual management necessary. Stones formed in a continent reservoir Stones in patients with neurogenic bladder disorder General considerations for recurrence prevention (all stone patients) • Drinking advice (2. Careful patient follow-up and effective precentive strategies are important. PNL and antegrade flexible URS are frequently used endourological procedures. 320 Urolithiasis .

initially 25 mg/day. increasing up to 50 mg/day Urolithiasis 321 .Pharmacological treatment of calcium oxalate stones (Hyperparathyreoidism excluded by blood examination) Risk factor Hypercalciuria Hyperoxaluria Hypocitraturia Enteric hyperoxaluria Suggested treatment Thiazide + potassium citrate Oxalate restriction Potassium citrate Potassium citrate Calcium supplement Oxalate absorption Small urine volume Distal renal tubular acidosis Primary hyperoxaluria Increased fluid intake Potassium citrate Pyridoxine LE 1a 2b 1b 3-4 2 3 1b 2b 3 GR A A A C B B A B B Pharmacological treatment of calcium phosphate stones Risk factor Hypercalciuria Rationale Calcium excretion > 8 mmol/day Medication Hydrochlorothiazide.

Inadequate urine pH pH constantly > 6. Primary HTP can only be cured by surgery.2 L-Methionine. 322 Urolithiasis . If HPT is suspected. with the aim of reducing urine pH to 5.8-6. 200500 mg 3 times daily. a neck exploration should be carried out to confirm the diagnosis.2 Antibiotics Urinary tract infection Eradication of urea-splitting bacteria hyperparathyroidism Elevated levels of ionized calcium in serum (or total calcium and albumin) require assessment of intact parathyroid hormone (PTH) to confirm or exclude suspected hyperparathyroidism (HPT).

GR: C) Urine pH constantly > 6. 100 mg/day (LE: 3.2 Allopurinol. 100-300 mg/day.0 mmol/day Hyperuricosuria and hyperuricemia > 380 µmol Urolithiasis 323 . targeted urine pH 5.0.0-7. ‘acidic arrest‘ in uric acid stones Medication Inadequate urine pH Alkaline citrate OR Sodium bicarbonate Prevention: targeted urine pH 6.8 Chemolitholysis: targeted urine pH 7. GR: B) Allopurinol.2 Adequate antibiotics in case of urinary tract infection L-Methionine.5 in ammonium urate stones Hyperuricosuria Uric acid excretion > 4. depending on kidney function (LE: 4. 200500 mg 3 times daily.Pharmacological treatment of uric acid and ammonium urate stones Risk factor Rationale for pharmacological therapy Urine pH constantly < 6.2-6.8-6.

struvite and infection stones Therapeutic measure recommendations Surgical removal of the stone material as completely as possible Short-term antibiotic course Long-term antibiotic course Urinary acidification: ammonium chloride.5 mmol/ day Medication Cystinuria Tiopronin.0-3. 1 g x 2-3 daily Urinary acidification: methionine. GR: B) 324 Urolithiasis . 1 to 3 times daily Urease inhibition 3 3 3 3 1b B B B B A LE GR Pharmacological treatment of cystine stones Risk factor Rationale for pharmacological therapy Cystine excretion > 3. upto a maximum dose of 2 g/day NB: TACHYPHYLAXIS IS POSSIBLE (LE: 3. 200-500 mg. 250 mg/day initially.

5-8.8-dihydroyadenine stones and xanthine stones Both stone types are rare. diagnosis and specific prevention is similar to that of uric acid stones. family history) • Dietary habits • Medication chart • Ultrasound in case of a suspected stone • NCCT (Determination of the Houndsfield unit provides information about the possible stone composition) • Creatinine • Calcium (ionized calcium or total calcium + albumin) • Uric acid Diagnostic imaging Blood analysis Urolithiasis 325 .5 Alkaline Citrate or Sodium Bicarbonate Dosage is according to urine pH (LE: 3. investigating a patient with stones of unknown composition Investigation Medical history Rationale for investigation • Stone history (former stone events. GR: B) 2.Inadequate urine pH Improvement of cystine solubility Urine pH optimum 7. In principle.

minimum 4 times a day) • Dipstick test: leucocytes.uroweb.org/ guidelines/online-guidelines/.http://www. erythrocytes. available to all members of the European Association of Urology at their website . 326 Urolithiasis . protein. specific weight • Urine culture • Microscopy of urinary sediment (morning urine) This short booklet text is based on the more comprehensive EAU guidelines ISBN: 978-90-79754-96-0. urine pH. nitrite.Urinalysis • Urine pH profile (measurement after each voiding.

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